Drug errors harm 1.5 million people each year, report finds

October 2006 Vol. 1 Num. 1

Author: Haron K. Baranoski, RN, MSN, FAAN

Institute of Medicine outlines comprehensive remedial approach

Adverse drug events (ADEs) harm at least 1.5 million people each year, and hospital patients experience at least one medication error each day, on average. These are some of the alarming conclusions of an Institute of Medicine (IOM) report released in July 2006.

According to the report, “Preventing Medication Errors,” at least 25% of harmful ADEs are preventable. (ADEs encompass all mistakes involving prescription drugs, over-the-counter products, vitamins, minerals, and herbal supplements.) Errors are common at every step of the medication process—procuring, prescribing, administering, and monitoring.

Although accurate data on preventable ADEs are hard to come by, various studies estimate that each year at least 380,000 preventable ADEs occur in hospitals, 800,000 in long-term care facilities, and 530,000 among Medicare outpatients. ADEs cost the nation an estimated $3.5 billion annually, not including lost earnings and other indirect costs.

Errors are most common during prescribing and administration. Studies show varying rates of prescribing errors, ranging from 12.3 to 1,400 per every 1,000 hospital patient admissions.

Recommendations to reduce ADEs

To reduce ADEs, the IOM report outlines a comprehensive approach involving nurses, physicians, pharmacists, and others in the healthcare industry. Recommendations include the following:

•By 2010, all prescriptions should be written electronically and all pharmacies should be able to receive prescriptions electronically, to reduce errors from illegible handwriting.

•Healthcare providers should use information technologies—especially point-of-care reference tools (such as personal digital assistants and the Internet)—to stay current on the latest drug information.

•Patients should take a more active role in their own medical care, learn about their drugs, and take more responsibility for monitoring drug effects.

•Healthcare providers should teach patients what to do if they experience side effects and should be more forthcoming about drug errors that have occurred.

•Federal agencies should work together to improve medication information leaflets, make more drug information available on the Internet, and develop a 24-hour, multilingual national telephone helpline to give consumers easy access to drug information.

The IOM report points out that nurses have primary responsibility for drug administration in acute and long-term care settings. Yet, the administration step has fewer safeguards and support mechanisms and commonly relies on a single healthcare professional.

Nurses also play a crucial role in intercepting medication errors. One study cited in the IOM report found that nurses intercepted 86% of errors made by physicians, pharmacists, and others. For steps you can take to decrease ADEs, see how nurses can make drug administration safer. For the complete report, visit http://

newton.nap.edu/catalog/11623.html#toc. For a summary, visit www.iom.edu/CMS/3809/22526/35939/35943.aspx.